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Provide a brief summary of this surgical procedure and its indications here.


A tracheotomy is done un
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, tracheotomy is indicated to protect the larynx from injury. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.


A tracheotomy should be performed following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis.  
In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin.  


== Preoperative management ==
== Preoperative management ==
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|-
|-
|Hematologic
|Hematologic
|
|If malignancy or chronic disease, coagulopathies or anemia may be present
|-
|-
|Renal
|Renal
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* Head and Neck CT/MRI  
* Head and Neck CT/MRI  
* CXR, ABG as indicated from H&P


=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===


=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
* Standard premedication if elective
** Avoid if critically ill of symptoms upper airway obstruction


=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
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=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
* Supine, head extended


=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
{| class="wikitable"
|+
!
!
|-
|General
|
* Consider TIVA with propofol/remifentanil
* Muscle relaxation required, may use rocuronium
* To avoid ETT cuff puncture, may advance closer to carina before trachea opened
* Slowly remove ETT under visualization of surgeon however do not remove completely
* Once tracheostomy tube secured, connect to circuit/suction
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits
|-
|Awake
|
|}


=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
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=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum
{| class="wikitable"
|+
!
!
|-
|ICU patients
|
* Continue on ventilatory support in the ICU
* Careful suctioning
* Do not remove for 5-7 days until track formed
|-
|
|
|-
|
|
|}


=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===


=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
* Bleeding
* Cellulitis / tracheitis
* Tracheal stenosis
* Pneumothorax
** Seen if low neck dissection of false passage formation
* Pneumomediastinum
* Creation of false passage during procedure
** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)
** Signs include absent end tidal, increased PIP
** If suspect, should attempt to reintroduce existing ETT
* Occlusion of tracheostomy tube
** Secretions, mucus plug, blood, mainstem
* Tracheostomy tube displacement
** Re-intubate orally or through trach site


== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

Revision as of 14:29, 19 February 2022

Tracheotomy
Anesthesia type

General, local

Airway
Lines and access

PIV

Monitors

Standard

Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
Article quality
Editor rating
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User likes
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Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, tracheotomy is indicated to protect the larynx from injury. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.

In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin.

Preoperative management

Patient evaluation

System Considerations
Neurologic
Cardiovascular
Respiratory
Gastrointestinal
Hematologic If malignancy or chronic disease, coagulopathies or anemia may be present
Renal
Endocrine
Other

Labs and studies

  • Head and Neck CT/MRI
  • CXR, ABG as indicated from H&P

Operating room setup

Patient preparation and premedication

  • Standard premedication if elective
    • Avoid if critically ill of symptoms upper airway obstruction

Regional and neuraxial techniques

Intraoperative management

Monitoring and access

Induction and airway management

Positioning

  • Supine, head extended

Maintenance and surgical considerations

General
  • Consider TIVA with propofol/remifentanil
  • Muscle relaxation required, may use rocuronium
  • To avoid ETT cuff puncture, may advance closer to carina before trachea opened
  • Slowly remove ETT under visualization of surgeon however do not remove completely
  • Once tracheostomy tube secured, connect to circuit/suction
  • Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits
Awake

Emergence

Postoperative management

Disposition

  • Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum
ICU patients
  • Continue on ventilatory support in the ICU
  • Careful suctioning
  • Do not remove for 5-7 days until track formed

Pain management

Potential complications

  • Bleeding
  • Cellulitis / tracheitis
  • Tracheal stenosis
  • Pneumothorax
    • Seen if low neck dissection of false passage formation
  • Pneumomediastinum
  • Creation of false passage during procedure
    • Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)
    • Signs include absent end tidal, increased PIP
    • If suspect, should attempt to reintroduce existing ETT
  • Occlusion of tracheostomy tube
    • Secretions, mucus plug, blood, mainstem
  • Tracheostomy tube displacement
    • Re-intubate orally or through trach site

Procedure variants

Variant 1 Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

Top contributors: Helen Heymann and Chris Rishel

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